A nurse is caring for a client in a critical care unit who suffered a knife wound to the chest. The nurse suspects the client is developing cardiac tamponade. Which of the following assessment findings should the nurse identify as supporting this suspicion?

Bradycardia.

Muffled heart sounds

Flattened neck veins.

Sudden lethargy.

Answer and Explanation

The Correct Answer is B

B. Muffled heart sounds, often described as distant or indistinct, are classic findings in cardiac tamponade. The accumulation of fluid in the pericardial sac dampens the transmission of sound from the heart to the chest wall, resulting in muffled heart sounds on auscultation. This finding is known as Beck's triad, which also includes hypotension and jugular venous distention.

A. Bradycardia is not a typical finding in cardiac tamponade. In fact, tachycardia is more commonly observed due to the compensatory response to decreased cardiac output and decreased stroke volume. The sympathetic nervous system is activated, leading to an increase in heart rate as a compensatory mechanism to maintain cardiac output.

C. Flattened neck veins are not consistent with cardiac tamponade. In cardiac tamponade, jugular venous distention (JVD) is typically observed due to increased venous pressure resulting from impaired right ventricular filling. The presence of JVD is an important clinical finding in cardiac tamponade and can help differentiate it from other causes of shock.

D. Sudden lethargy can occur in various medical emergencies, including cardiac tamponade, but it is not a specific or diagnostic finding for this condition. In cardiac tamponade, symptoms may include dyspnea, chest pain, hypotension, and signs of decreased cardiac output such as cool extremities and altered mental status. However, sudden lethargy alone may not be specific enough to confirm cardiac tamponade.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is ["A","C","D","E"]

Explanation

A. Hypotension may result from decreased cardiac output due to hypoxemia and acidosis or as a compensatory response to hypoxia-induced vasodilation. Therefore, monitoring for hypotension is important in ARF.

C. Hypoxemia can impair cerebral perfusion and neuronal function, leading to alterations in mental status ranging from confusion to coma. Decreased level of consciousness is a concerning sign of inadequate oxygenation and should be closely monitored in patients with ARF.

D. Dyspnea, or difficulty breathing, is a hallmark symptom of respiratory failure. In ARF, the respiratory system's inability to adequately oxygenate or ventilate leads to increased work of breathing and feelings of breathlessness. Patients with ARF often experience severe dyspnea as they struggle to maintain adequate gas exchange.

E. Headache is not typically considered a primary manifestation of ARF. However, it may occur as a secondary symptom due to factors such as hypoxemia, hypercapnia, or acidosis. Patients with ARF may experience headache as a result of cerebral vasodilation in response to hypoxia or as a symptom of underlying conditions contributing to respiratory failure.

B. Nausea is not a typical manifestation of ARF itself. However, it may occur as a secondary symptom due to factors such as hypoxia, acidosis, or medications administered for the management of ARF. While nausea may be present, it is not a direct result of respiratory failure.

A. The patient has no cough reflex when suctioned. B. The patient's oxygen saturation is 90% to 93% C. The patient does not respond to voice. D. No sedative is ordered for the patient

Correct Answer is D

Explanation

D Sedatives are typically administered alongside neuromuscular blockers to ensure the patient's comfort and prevent awareness during mechanical ventilation.

A The absence of a cough reflex when suctioned is expected in a patient receiving cisatracurium (Nimbex) because it is a neuromuscular blocking agent that induces paralysis. Cisatracurium inhibits skeletal muscle movement, including the muscles involved in coughing.

B An oxygen saturation between 90% to 93% is within an acceptable range for a patient in this condition.

C The lack of response to voice may indicate that the patient is sedated or experiencing effects from the neuromuscular blocking agent. However, since the patient is receiving cisatracurium to prevent asynchronous breathing with the positive pressure ventilator, it's expected that the patient will not respond to voice due to the medication-induced paralysis.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a client in a critical care unit who suffered a knife wound to the chest. The nurse suspects the client is developing cardiac tamponade. Which of the following assessment findings should the nurse identify as supporting this suspicion?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has an acute respiratory failure (ARF). The nurse should monitor the client for which of the following manifestations of this condition? (Select all that apply.)

Correct Answer is ["A","C","D","E"]

Explanation

Which information about a patient who is receiving cisatracurium (Nimbex) to prevent asynchronous breathing with the positive pressure ventilator requires action by the nurse?

Correct Answer is D

Explanation

A nurse is caring for a client who reports heart palpitations. An ECG confirms the client is experiencing ventricular tachycardia (VT). The nurse should anticipate the need for taking which of the following actions?

An 81-yr-old patient who has been in the intensive care unit (ICU) for a week is now stable and transfer to the progressive care unit is planned. On rounds, the nurse notices that the patient has new onset confusion. What should the nurse plan to do?

A nurse is monitoring a client who is receiving a unit of packed RBCs following surgery. Which of the following assessments is an indication that the client might be experiencing circulatory overload?

A nurse is caring for a client who has pericarditis and reports feeling a new onset of palpitations and shortness of breath. Which of the following assessments should indicate to the nurse that the client may have developed atrial fibrillation?

A nurse in an emergency department is caring for a client who has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take?

A nurse is caring for a client who is in the compensatory stage of shock. Which of the following findings should the nurse expect?

Which of the following medications is commonly used for afterload reduction in critical care?

Which is(are) potential result(s) of end-organ damage from chronic hypertension? (Select all that apply.)